United States District Court, D. Oregon
NATALIE Y. ACTON, Plaintiff,
CAROLYN COLVIN, Commissioner, Social Security Administration, Defendant.
John E. Haapala, Jr., Haapalaw LLC, Law Office of John E. Haapala, Jr., Eugene, OR, Attorney for Plaintiff.
S. Amanda Marshall, United States Attorney, Ronald K. Sliver, Assistant United States Attorney, U.S. Attorney's Office District of Oregon, Portland, OR, Heather L. Griffith, Special Assistant United States Attorney, Office of the General Counsel, Social Security Administration, Seattle, WA. Attorneys for Defendant.
OPINION & ORDER
MARCO A. HERNANDEZ, District Judge.
Plaintiff Natalie Y. Acton brings this action for judicial review of the Commissioner's final decision denying her application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act. This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). For the following reasons, I reverse the Commissioner's decision and remand for further administrative proceedings.
Ms. Acton was born in 1966 and was 39 years old at the alleged onset of disability. (Tr. 107.) She completed the ninth grade and reports past work in assembly, delivery, and as a substitute U.S. Postal Service worker. (Tr. 133, 128.) On April 3, 2006, Ms. Acton tripped and fell while delivering papers. (Tr. 370.) On April 5, 2006, Ms. Acton visited her primary care provider, Dr. Richard Williams, and complained of constant pain in her knee, leg, and ankle. (Tr. 292.) Dr. Williams diagnosed a sprained left ankle and bruised left knee. Id . X-rays performed on April 2006 showed no fracture or bony lesion, normal alignment, and unremarkable soft tissue. (Tr. 295.) On May 31, 2006, Ms. Acton saw Dr. Douglas Morrison who noted her leg appeared morphologically normal, with no swelling, no obvious changes in skin appearance, and no edema. (Tr. 242.) Dr. Morrison gave a "working diagnosis of regional pain syndrome versus mechanical derangement" in the knee, and ordered an MRI. Id . Ms. Acton's MRI, conducted on June 2006, showed no abnormalities in the knee, except for "mild but nonspecific marrow edema, and mild narrowing of the articular cartilage compartment consistent with only mild chondromalacia, " also known as runner's knee. (Tr. 244.) Dr. Morrison then referred Ms. Acton to Dr. Mark Greenberg, a pain specialist. (Tr. 242.)
Dr. Greenberg examined Ms. Acton on July 20, 2006, and noted her knee was not discolored or swollen. (Tr. 474.) Dr. Greenberg found "some crepitans to palpation over the patella ligament and suprapatellar bursa." Id . He found no tenderness to palpation, no texture changes on the affected skin, and no unusual patterns of swelling, hair, or nail growth. Id . Dr. Greenberg remarked that Ms. Acton's signs and symptoms were consistent with complex regional pain syndrome ("CRPS"), and recommended a nerve block. Id.
The next day Ms. Acton saw yet another doctor, Dr. Sheila Algan, who reported no swelling on the leg, but noticed a "slight dusky appearance." (Tr. 255.) Dr. Algan found some "fairly advanced quadriceps atrophy, " but otherwise described the exam as "fairly unremarkable." Id . Dr. Algan indicated probable CRPS with deconditioning in the left leg. Id . Dr. Algan noted she "concur[red] with Drs. Morrison and Greenberg, " and recommended physical therapy. (Tr. 256.)
On August 31, 2006, Ms. Acton saw Dr. Joseph Savino. (Tr. 458.) Ms. Acton explained having pain, and suffering hypersensitivity to light and touch on her knee. Id . Dr. Savino's physical examination revealed no appreciable color difference, no edema, and no difference in temperature between Ms. Acton's knees. Id . Dr. Savino wrote that Ms. Acton demonstrated "overdramatized pain behavior." (Tr. 459.) His pain assessment showed "inconsistencies" with her reported pain and his physical examination. Id . She was significantly anxious, and demonstrated "somatic preoccupation, " which "magnif[ied] her symptoms greatly." Id.
Ms. Acton visited another physician, Dr. Michael Narus, on November 6, 2006. (Tr. 262.) Dr. Narus recorded her reports of severe pain in her left knee and the beginning of pain in her right knee. Id . Dr. Narus found some tenderness to palpation on the left knee, but he "doubt[ed]" the presence of reflex sympathetic dystrophy. (Tr. 263.) Dr. Narus referred Ms. Acton for an electrodiagnostic evaluation. Id.
Dr. Peter Grant performed the electrodiagnostic test. (Tr. 267.) Although Ms. Acton continued to report pain in her left knee, the exam showed no acute, chronic, or old abnormalities of the muscle membranes or motor units. (Tr. 268.) All additional electrodiagnostic results showed Ms. Acton's left leg was normal. Id . Dr. Grant reported that while some of Ms. Acton's symptoms might suggest CRPS, he could not find objective evidence to support such a diagnosis. (Tr. 269.) Dr. Grant found no temperature change and no color or trophic skin changes in any area of her left leg. Id . He stated that Ms. Acton had no atrophy and explained such muscle loss would be present if she had significant CRPS for the previous five or six months. Id.
Ms. Acton returned to Dr. Williams, her primary care physician, twice in July and August of 2007. (Tr. 287-90.) The medical reports from both visits reflect Ms. Acton's complaints about leg pain, but again, the physical exam revealed no abnormalities. Id . Finally, on April 25, 2008, Ms. Acton saw Dr. Zakir Ali, who noticed Ms. Acton did not have the classical manifestations of CRPS. (Tr. 283.)
Ms. Acton filed a claim for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act (the "Act") on June 10, 2009, (Tr. 107) and on June 17, 2009, she applied for Disability Insurance Benefits ("DIB") under Title II of same Act. (Tr. 111.) Ms. Acton alleges disability since April 3, 2006, due to CRPS. (Tr. 107, 111, 127.) The Commissioner denied her disability insurance benefits claims on November 12, 2009, and upon reconsideration on February 9, 2010. (Tr. 46, 53.) On August 23, 2011, Ms. Acton appeared at a video hearing before an Administrative Law Judge ("ALJ"). (Tr. 25.) On September 21, 2011, the ALJ found Ms. Acton not disabled. (Tr. 19.) The Appeals Council declined review of the matter on December 6, 2012, making the ALJ's decision the final decision of the Commissioner. (Tr. 1.)
SEQUENTIAL DISABILITY ANALYSIS
The Act defines "disability" as the "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or that has lasted or can be expected to last for a continuous period of no less than twelve months." 42 U.S.C. §§ 416(i)(1), 1382c(a)(3)(A) (2012). The ALJ engages in a five-step sequential process to determine whether a person is disabled under the Act. 20 C.F.R. §§ 404.1520, 416.920 (2013). Each step is potentially dispositive. At step one, the ALJ determines whether the claimant is engaged in substantial gainful activity. If so, the claimant is not disabled; if not, the analysis moves to step two. 20 C.F.R §§ 404.1520(b), 416.920(b) (2013). At step two, the ALJ determines whether the claimant has one or more severe impairments. If not, the claimant is not disabled; if so, the analysis continues. 20 C.F.R §§ 404.1520(c), 416.920(c) (2013). At step three, the ALJ determines whether the claimant's impairment "meets or equals" one of the impairments listed in the Social Security Administration ("SSA") regulations, 20 C.F.R Part 404, Subpart P, Appendix 1. If so, the claimant is disabled. If the claimant's impairment does not meet or equal one listed in the regulations, the analysis moves to step four. 20 CFR §§ 404.1520(d), 416.920(d) (2013).
If adjudication proceeds beyond step three, the ALJ must first evaluate the medical and other relevant evidence in assessing the claimant's residual functional capacity ("RFC"). The RFC is an assessment of work-related activities the claimant may still perform on a sustained basis, despite the claimant's impairments. 20 C.F.R. §§ 404.1520(e), 416.920(e) (2013); Smolen v. Chater, 80 F.3d 1273, 1291 (9th Cir. 1996); SSR 96-8p, 1996 WL 374184, at *2 (July 2, 1996). Assessing a claimant's credibility regarding his or her symptoms and their functional effect is part of the RFC determination when the record establishes the existence of a medically determinable impairment that could reasonably give rise to the claimant's reported symptoms. Robbins v. Soc. Sec. Admin., 466 F.3d 880, 883 (9th Cir. 2006). The ALJ uses this information to determine whether the claimant can perform his or her past relevant work. 20 C.F.R. §§ 404.1520(f), 416.920(f) (2013). If the claimant cannot perform his or her past ...